Resuscitation in the Elderly

Dr Ryen, I just had a really distressing conversation with my dad’s doctor. He was brought into hospital because he fell and broke his hip. Dad is 86 years old. He's certainly not as nimble as he used to be, but he still lives in his own home (with a housekeeper and some help with meals). Anyway, the trouble came when the surgeon came to see us. After he explained that Dad would need a partial hip replacement, the surgeon said, “So, if he has a massive heart attack or something, you don’t want us to save him, right?” I was appalled! Then he backtracked and tried to talk us OUT of doing everything for my dad if he were to collapse suddenly. I was going to write a formal letter of complaint, but some of my nursing friends suggested otherwise. What gives? Do we just let our dear parents die now?!  

- Sandra, Duluth, MN

Hi Sandra, sounds like you’ve had a rough week. So sorry to hear about your dad breaking his hip. Sadly, this is a very common problem in the elderly. Your concerns are absolutely valid, but I think there may be some misunderstanding going on. Unfortunately, your dad’s orthopedic surgeon may not have broached this sensitive issue the right way. 

First, let’s talk about frailty. This is the inability to cope with stressors like we used to. A healthy young adult can break a bone or catch pneumonia and be expected to make a full recovery with appropriate care. However, that same individual at 86 years old takes far longer to recover, if they ever do at all. I hear this question all the time from patients’ relatives: “Mom was doing so well at home before her surgery. Why isn’t she getting better? She can’t even walk anymore!” Simply put, elderly patients don’t bounce back like they used to. Also, our perception that they’re doing fine at home is rarely accurate. In reality, frail adults are often barely coping. Sometimes it’s only a matter of time before a stiff breeze topples them over and everything falls apart. 

Second, resuscitation in a hospital is incredibly aggressive. If a patient’s heart suddenly stops, the medical staff will trigger a Code Blue to try to restart it. People rush in from all over the hospital. Chest compressions shatter the ribs. Huge electric shocks revert deadly heart rhythms back to normal. A breathing tube is inserted in the throat to ventilate the lungs. Otherwise dangerous medications are pushed into the bloodstream to improve the cardiovascular system. In short, emergency resuscitations are not a walk in the park. They're often unsuccessful even in young patients. Very few elderly patients a Code Blue. Even if their heart is somehow restarted, most never leave the hospital alive.

Such extreme resuscitation (“heroic measures”) are not something that elderly patients typically want in the first place. I often put it to my patients like this: “Bob, if you were to drop down dead and start floating up to heaven, do you want us to drag you back down to earth?” Then everyone laughs and Bob replies that of course he wouldn’t want that. “If it’s my time, just let me go,” he says, and the vast majority of family members wholeheartedly agree with his wishes.

Now, I’m sure your surgeon was fully prepared to do everything he could to prevent your dad from ever getting to that point. But sometimes - especially in the elderly - devastating medical events sneak up on us. Standard hospital practice is to “do everything” to improve patients’ health... within reason. This includes IV fluids, antibiotics, basic surgeries, and comfort care. However, all hospital staff have been stuck treating patients in such a way that they didn’t think was appropriate, specifically Code Blues on the frail and elderly. Think of a terminally ill cancer patient kept alive on a ventilator with no chance of recovery. Everyone in health care has seen it, and it’s awful. We all go home to our families and make them promise us that if we’re ever in that position, they’ll just let us go. 

I suspect that’s what your dad’s orthopedic surgeon was getting at. Fixing the broken hip is entirely appropriate, but what he wants to avoid is unnecessarily prolonging suffering and trying to treat conditions that shouldn’t be treated, namely massive heart attacks, strokes, and other deadly complications.

To be honest, Sandra, your dad’s hip fracture may be the beginning of the end. With proper care, he should recover somewhat, but he likely won’t ever get back to where he was before. He’s prone to complications - delirium, infection, stroke, clots, etc. - that will further threaten his health. It’s certainly appropriate to treat conditions as they arise, but what most health care providers don’t want is to force unnecessary and futile treatments on an elderly patient who would never have wanted them in the first place. I suspect everyone working for your dad has his best interests in mind, as you do - it’s often just a matter of getting on the same page.

Hope that helps.

© D. B. Ryen Incorporated, August 2021.  

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